Pancreatic Pseudocyst

What is Pancreatic Pseudocyst?

A true cyst is a pocket filled with fluid that is lined on the inside by a specific type of tissue called epithelial tissue. A pseudocyst, on the other hand, doesn’t have this special lining; instead, it’s enclosed by a wall made of fibrous and healing (granulation) tissue. That’s why it’s called a “pseudo”, or fake, cyst. A pancreatic pseudocyst is a pouch of fluid that’s surrounded by a thick wall, typically found near or on the pancreas, which typically doesn’t contain any dead tissue. It’s often a result of chronic pancreatitis (lasting inflammation of the pancreas) and less likely to result from acute pancreatitis (short but severe inflammation). This pseudocyst can happen when the passages draining fluids from your pancreas get damaged, often due to gallstones or alcohol misuse, leading to the pooling of pancreatic fluid. But, this condition is pretty rare, affecting at most one out of 100,000 adults per year.

The symptoms of a pancreatic pseudocyst are not very straightforward and can be things like a vague stomach pain, feeling sick, or throwing up. However, if you’ve had pancreatitis before and there’s a finding of a thick-walled, clear-bordered and fluid-filled lump near the pancreas on an imaging scan, it’s probably a pancreatic pseudocyst. A CT scan, which uses x-rays to create detailed images of the body, is usually the go-to method for diagnosing this condition. Most of the time, pseudocysts resolve by themselves and only need supportive care while the body does its healing. Larger pseudocysts might produce more noticeable symptoms and complications. The longer the symptoms persist, the more likely it is that extensive care is needed. Possible complications can include infections, severe bleeding, pseudocyst rupture, and damage to the pancreatic duct system, which is why regular follow-ups are key to catch any complications early. Monitoring the size of the cyst through ongoing scans is also necessary.

If symptoms get worse or complications arise, plenty of treatment options are available based on the condition and tolerance level of the patient. Percutaneous drainage, which is a less invasive process to remove the fluid, can be considered for patients who can’t go through invasive procedures. Endoscopic procedures, though, are gaining popularity, especially with the introduction of endoscopic ultrasound. Surgery, while highly effective, specifically for large and complex pseudocysts, is seen as the last resort. It’s vital for patients to know the risks and benefits linked to each treatment and to involve expert teams, including internal medicine doctors, endoscopists, interventional radiologists, and surgeons, in case of more complex conditions, to get the best results.

In summary, a pseudocyst is a condition that needs careful attention and management, with the teamwork of different specialists being crucial in handling this intriguing disease.

What Causes Pancreatic Pseudocyst?

Pseudocysts are a type of fluid-filled sac that form in the pancreas when the main pancreatic duct, or its branches, are damaged, either by inflammation or direct injury. This allows the pancreatic juices, which help in digestion, to leak into the pancreas and over time, they form a distinct collection, known as a pseudocyst. Pseudocysts can also develop as a complication from another condition, called pancreatitis, which is inflammation of the pancreas.

The reasons why pseudocysts form are generally the same as the causes of pancreatitis. In places where alcohol consumption is higher, drinking alcohol seems to be the main cause of pseudocysts, and is responsible for over 70% of the cases. Other reasons can include gallstones, injuries, or unexplained causes (which doctors often refer to as ‘idiopathic’).

Typically, a pseudocyst develops after an instance of acute pancreatitis (an abrupt flare-up of inflammation in the pancreas) usually in about 4 to 6 weeks after that flare-up. The pseudocyst is enclosed within a solid wall made up of tissue that helps in healing and has a fluid inside rich in an enzyme called amylase. Roughly one-third of pseudocysts form near the ‘head’ of the pancreas (the wider part), while the other two-thirds occur in the ‘tail’ (the thinner part). It is not very clear how pseudocysts develop in long-lasting, or chronic, pancreatitis. It may happen due to a worsening of ongoing pancreatitis because of new gallstones or plugs of protein forming in the pancreatic ducts, which are small tubes in the pancreas.

Risk Factors and Frequency for Pancreatic Pseudocyst

Pseudocysts, which can happen after pancreatitis, affect people of all ages. They tend to be more common in males because pancreatitis itself is more often seen in males. Among those with acute pancreatitis, between 5% to 16% may develop pseudocysts. However, in cases of chronic pancreatitis, the chances of getting pseudocysts rise, affecting 20% to 40% of patients. This is likely because of the extended nature of the disease which can lead to more damage to the pancreatic ducts. A detailed analysis from Wayne University Hospital in Detroit showed that most cases of pancreatic pseudocysts were caused by alcohol abuse (70%), followed by diseases of the bile ducts (8%), injuries (6%), and some with unknown causes.

• Pseudocysts can happen after pancreatitis in any age group.
• They are more common in males, following the trend of pancreatitis.
• The incidence of pseudocysts is between 5% to 16% in acute pancreatitis cases.
• In chronic pancreatitis cases, the incidence rises to between 20% to 40%.
• Most pseudocyst cases were found to be caused by alcohol abuse (70%), followed by diseases of the bile ducts (8%), injuries (6%), and some of unknown origins.

Signs and Symptoms of Pancreatic Pseudocyst

A pseudocyst is a health condition that doesn’t have any unique or specific symptoms. That said, if someone who recently suffered from pancreatitis experiences chronic abdominal pain, it could hint towards a pseudocyst. Typical signs and symptoms can include:

• Long-lasting abdominal pain
• Lack of appetite
• Newly developed mass in the abdomen after pancreatitis
• Yellowish skin or shock, although less common

Furthermore, certain findings may suggest a pseudocyst, but their absence doesn’t necessarily rule out this condition. These include:

• Abdominal tenderness or soreness
• A noticeable mass in the abdomen
• Signs of an infection in the abdomen, like hardening or tightness (if the cyst bursts)
• Fever
• Yellowing of the whites of the eyes
• Excess fluid in the lung space

Testing for Pancreatic Pseudocyst

If your doctor suspects a pancreatic pseudocyst – a fluid-filled sac on the pancreas – you may first get an abdominal ultrasound. This is often the first test because it’s easy to do, affordable, and can be done on the spot. The ultrasound can detect the pseudocyst about 70% to 90% of the time. One downside is that the results can vary, depending on the skill of the person performing the ultrasound.

A better option for the initial imaging may be a contrast-enhanced CT scan of the abdomen. This type of scan is very proficient in detecting pancreatic pseudocysts, with accuracy rates between 82% to 100%. It also offers a clearer view of the organs around the pancreas. A CT scan can identify gallstones or calcifications that could be connected to your symptoms, and it can tell the difference between debris and areas of pancreatic tissue death. However, one limitation of a CT scan is that it can’t distinguish between a pseudocyst and cancerous cystic lesions.

An endoscopic ultrasound (EUS) might be used if it’s crucial to tell a pseudocyst from a cancerous lesion. An EUS is a minimally invasive procedure that provides a very detailed image of the pancreas. It can also aid in draining the cyst if required. Certain findings like cyst thickness, the presence of dividing walls within the cyst, a solid mass or nodule, or abnormal enlargement of the main pancreatic duct, may indicate a cystic cancer.

An MRI-MRCP, a type of specialized MRI, provides the most accurate look at the pancreatic ducts. It’s better than a CT scan when it comes to identifying debris within the pseudocyst. But it’s not typically used because a CT scan usually provides enough information. An MRI-MRCP might be used in specific cases when knowing exactly what is in the pseudocyst can help avoid complications such as infection or bleeding.

Treatment Options for Pancreatic Pseudocyst

Pseudocysts, or fluid-filled sacs that can form in your body, often resolve on their own, especially if related to an episode of acute pancreatitis (a sudden inflammation of the pancreas). For stable, non-growing pseudocysts that don’t cause discomfort, doctors usually recommend a conservative approach. This can include pain relievers, anti-nausea medications, and a low-fat diet as needed. Regular medical imaging is also done to monitor the pseudocyst’s size and promptly spot any potential growth or complications.

On the other hand, pseudocysts that develop due to chronic (long-term) pancreatitis rarely go away on their own. Factors such as having multiple cysts, cysts near the end of the pancreas, other local complexities such as blockages or hard deposits within the pancreatic ducts, and an increasingly growing cyst size are associated with a lower chance of spontaneous resolution. Emergency treatment may be required if complications like inflammation of the peritoneum (the membrane lining the abdomen), infection, bleeding, or gastric outlet obstruction occur. Symptoms like severe abdominal pain, constant nausea, vomiting, poor oral intake, fevers, chills, or low blood pressure should be taken seriously.

Three main types of invasive treatment exist: percutaneous (via the skin), endoscopic (via an endoscope, a flexible tube with a camera), and surgical drainage or removal of the pseudocyst. Ideally, any invasive intervention is delayed until about six weeks after the triggering pancreatitis episode—if no other complications demand immediate action—to allow the pseudocyst’s wall to strengthen. However, in cases where the pseudocyst is suspected to be causing a life-threatening condition, immediate intervention is necessary, regardless of pseudocyst size or how long it’s been present.

Percutaneous Drainage, which involves guiding a small coil-shaped (pigtail) catheter into the pseudocyst using ultrasound or CT imaging, may be a source of discomfort due to frequent clogging and repositioning of the catheter. This technique is not recommended for patients with strictures (narrowed areas) in the pancreatic duct or who can’t carry out catheter care at home. When compared to surgical drainage or endoscopic drainage, percutaneous drainage has shown inferior outcomes with regards to residual fluid collections, frequency of re-intervention, and the need for surgery.

Endoscopic Drainage is gaining favor due to its less invasive nature compared to surgery and high rates of long-term success. The goal is to create an internal drainage pathway from the pseudocyst to the gut, thereby bypassing the need for an external drain. This can be accomplished either through the ducts of the pancreas (transpapillary drainage) or directly through the wall of the stomach or small intestine (transmural drainage).

Surgical Drainage was formerly the preferred method for treating pseudocysts but is now typically reserved for cases like recurrent pseudocysts, pseudocysts of uncertain origin, the need to remove a potentially cancerous cyst, or pseudocysts that are challenging to access endoscopically. Options for surgical drainage include procedures known as cystogastrostomy, cystoduodenostomy, or cystojejunostomy, which can be performed either via open surgery or the less invasive laparoscopic method. Both methods are effective, but laparoscopic surgery tends to have lower associated risks.

In conclusion, the treatment for pseudocysts varies based on an individual’s specific circumstances, and it’s important to fully understand the potential risks and benefits of each treatment option.

What else can Pancreatic Pseudocyst be?

There are a number of medical conditions that could be the cause if someone is experiencing symptoms similar to pancreatitis. Here are some of them:

• Pancreatic necrosis or abscess: This involves the death of pancreas tissue, which may present in patients dealing with pancreatitis who show signs of a severe infection and do not improve with standard treatment.
• Pancreatic Pseudoaneurysm: This can occur as a consequence of pancreatitis, where the arteries are worn away, leading to a quick increase in the size of a cyst, a sudden reduction in red blood cell count, and bleeding in the upper part of the digestive tract.
• Pancreatic cystic neoplasm: This appears as a cyst with multiple compartments and thick walls in the pancreas, with elevated levels of a certain type of antigen (CEA) in the cystic fluid. Symptoms can include weight loss and decreased appetite.
• There are also other conditions not directly related to the pancreas, such as stomach ulcers, stomach cancer, blocked intestines, ovarian tumors or cysts, heart attack, or pneumonia.

It’s crucial that doctors keep these potential diagnoses in mind when evaluating and treating a patient presenting with pancreatitis-like symptoms.

What to expect with Pancreatic Pseudocyst

Pancreatic pseudocysts often heal on their own, especially if they appear following an episode of acute pancreatitis. The healing process for these pseudocysts usually takes between 2 to 6 weeks. During this period, about a third of these cysts will clear up on their own without needing any treatment.

Possible Complications When Diagnosed with Pancreatic Pseudocyst

The aim is to prevent a variety of possible complications. These include:

• Infections that could occur post-procedure
• Breakage into the stomach or intestines, which could lead to bleeding
• Uncontrolled rupture into the abdominal area, resulting in severe stomach pain, inflammation, or at worst, death
• Reports of large fake cysts increasing pressure within the abdomen. This could lead to difficulties in breathing, pronunciation and body positioning, stomach pain, swelling, and new organ failure
• Formation of false aneurysms in the pancreas
• Pressure on the surrounding structures leading to complications with bile secretion or increased blood pressure in the portal vein system

Preventing Pancreatic Pseudocyst

A pseudocyst is a collection of fluids, usually from the pancreas, that gathers near the pancreas. These are frequently seen in individuals who have a history of long-term or chronic pancreatitis, and less often in those with short-term or acute pancreatitis. Certain factors make a person more likely to develop a pseudocyst, such as having gallstones, drinking alcohol, or experiencing a physical injury to the abdomen.

Pseudocysts are sometimes unnoticeable, meaning they don’t have any symptoms. Other times, they can cause vaguely defined symptoms like abdominal pain, feeling sick to the stomach, or throwing up. On a CT scan, which is a type of X-ray, a pseudocyst looks like a clear, round, fluid-filled mass near the pancreas.

If a pseudocyst doesn’t cause any complications, it often goes away on its own. Typically, the first steps in treatment are pain-relief medications, medicine to control nausea and vomiting, and a diet low in fat. If the symptoms persist or if there are complications like bleeding, infection, or an increase in the pseudocyst’s size, more aggressive treatments may be necessary.

There are certain warning signs that should cause you to seek immediate medical attention. These include vomit that looks like coffee grounds, a constant lack of appetite, unexplained weight loss, severe abdominal pain, persistent vomiting, or yellowing of the skin and eyes, which is a symptom of jaundice.